29-234 rIa �
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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 '
WORE ER'S COMPENSATTON INSURANCE A FIDAM
(licensecJpermittdre)
with a principal place of business/reJsidenc//e at:
�(St 14 A T 'one#) 3�t7—et/city/
do her eby certify, under the pains and penalties of pegury, that
(/am an employer providing the following worker's compensation coverage for my
employees worEng on this job-
(11 su o� Company) (Policy Number) (ExpirzGbn Date)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) Cmsurance Company/Policy Nurnbcr) (Expiration Date)
r.
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) Gasuurance Compaay/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attanh additioml short ifnocc�to include infoemitioa pataiaiag to all ooatrsd )
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:ptcs=be aware that while homcow who employ Palo=to do nn infmmoc cvastnraioa or repair work ou a dwtlliag of
not more than throe units in which the homoowner reside a on the grounds appurumaat ihacto arc not generally oo=tdcrrd to be
emptoyaa under the work compcawlion Ad(GL152-m 1(5)),application by a homeowner for a licrasc cc pa=il may cvidmcc the
legal dahrs of an employer under tho Workols C.ompomaiiou Act
I underhand that a copy of tbii ctatcment may ba forwarded to tho Deparmcad of Lekuftial Acadca&Ofhoo of In% anee for the
covaxgc vaific:&oa and that failure to&==coverage under scctioa 25A of MOL 152 can lead to the i n poaid-of aiminsl pcaalfles
oomistiug of a fine Of UP to S1,500.00 and/or bnprisommcat of up to oar year and civil pcaaltla is the form of n Stop Work Order and a
&so of S 100.00 a day against me.
For dcprtn=5 I ueo only
Permit Number
A,fapr{ Lot#
f
8 1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder 13 4,4,o
License Number
Address Expiration Date
Signature Telephone
en's e're " btne 'mproveriient°@ontractor� Not Applicable ❑
Company Name Registration Number
,> Fl /Slr2) i(�;� / ®e /9 a 0 0,2_
Address Expiration Date
✓1005/��ft� rn 7� �f`'�— Telephone
SECTION 10 1NORKERS' COMPENSATION INSURANCEAFFIDAVIT(MG.L. c. 152, §,25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this of
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... L/ No...... ❑
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)fan
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner,
as supervisor. CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person(s)who own a parcel of land on which he/she resides or intends to reside,on which th
is,or is intended to be, a one or two family dwelling,attached or detached structures accessory to such use and/or farm
structures.A person who constructs more than one home in a two-year period shall not be considered a homeowne
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153 (Liability of Employers t
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for pers
you hire to perform work for you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
V
SCCT1l N 1
se, O ID � E 4eW, ,
New House ❑ Addition ❑ Replacer n indows Alteration(s) ❑ Roofi ❑
Or Doors 1 J
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding Other[ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0- Sheet 0
Ea
Mew ho" 5t"se an`� o7-dif 67ezi g�houfikLdomple�ee the flo 6W n
a. Use of building: One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Mascheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes_
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECT ON 7a 9,WNERA,UT IORIZATION TO BE COMPLETED *WHEN
vC fi as y
OWNEISJGENT 0CQNRACTORrAPPJ.�ESPQa�UJL01(�G'PERMIT'
/C✓�/A) !� as Owner of the subject prc
hereby authorize +� L tc
My be alf,_in all matters relative to work authorized by this b ilding permit application.
a • ".a-'i r am �� J �,. 6 Ae� 0
Signature of Owner Date
asQww/Authorized Agen
hereby declare that the statements and info* ation on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
4r+°ew: n1 G' /�✓Q�1'
Print Name
0
Signature of CMW/Agent Date
,i
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO k1 DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW
YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ?YES—
No
IF YES, describe size, type and location:
•
f Northampton t
I i g Department # e.
2 Main Street
FEB 2
_ Rom 100 a v •. ;...
otstham ton, MA 01060 S , 4
40 Fax 413-587.1272 o ite n
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION i-'SITEANFORMATION
This section to'b com yip ice
e pletedbff
1.1 Property Address:
/� rv� A°��
Elfin St District CB District
SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
��
Name(Print) Curr�n t Maili Address: I0
Telephone _
Signature
f �" 3701
2.2 Authorized Agent:
�
n► 1..
g E t/ ' ' r?/1�� `� r` �/ 9�C /�,G' �Y✓0k'/ff�h, �C1� 1d!/Q.�
Name(Print) z / Current Mailing Address:
Signature Telephone
'5=11 ON 3 -IEST.' ED CONSTRUCTION COSTS,
Item Estimated Cost(Dollars)to be Official Use-Only
completed by ermit applicant
1. Building (a) Building Permit Fee'
/ci 2s
2. Electrical . (b) Estimated Total Cost of
Construction.from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 +4 + 5) blo Q Check Number
'Phis Section For Official UseO,nl
Bula�dgermftlurrber Date=issued
Signature BulldmgComrn is
signer/��nspector,of Baild�ggs Date ,
BP-2002-0725
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:29-234 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:replacement windows/siding BUILDING PERMIT
Permit# BP-2002-0725
Project# JS-2002-1194
Est. Cost: $8100.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: B & R Siding 100465
Lot Size(sa.ft.): 21954.24 Owner: FLYNN CARROLL s
Zoning:U1ZA Applicant: B & R Siding
AT. 134 SPRUCE HILL AVE
Applicant Address: Phone: Insurance:
781 Bridge Rd (413) 586-4167 Workers
Compensation
NORTHAMPTON MAO 1060 ISSUED ON:2125102 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS & SIDING
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 2/25/02 0:00:00 18098 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo